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Monday, June 30, 2014

Care Beyond Hospitals

Fish say, they have their
streams and ponds;
But is there anything beyond.

Rupert Brooke (1887-1915), English Poet

Currently hospitals have their revenue streams and their surgical ponds for collecting that revenue.

But for hospitals what lies beyond?

ObamaCare is cracking down on hospital Medicare and Medicaid revenues, penalizing hospitals for unsafe care, and imposing new more costly regulations.

But due to improved technologies and increased managerial efficiencies, specialists throughout the land are pulling out of hospital surgical units to create their own surgical ambulatory surgical centers in a variety of fields – ophthalmology, orthopedics, gastroenterology, general surgery, cosmetic procedures, orthodontics, podiatry , cosmetic procedures, orthodontics, podiatry.

You name the surgical specialty, and somewhere there is an ambulatory surgery center for it.

It is apparent specialists can perform many surgical procedures more safely, more cost efficiently, more effectively, more quickly, less bureaucratically, and more profitably outside of hospitals, rather than hospitals.

These factors are obvious to specialists, and they are moving fast to set up and to own their own surgical centers.

“He said the center, which opened about three years ago, offers patients cheaper, faster and more convenient care than a hospital.”

“Everyone is highly specialized,” he explained. “Typically, I can do two-and-a-half times as many cases at the surgery center in the same amount of time. And I’m not operating any faster. It’s the turnover of the room and the efficiency.”

“His center is not alone. Two more local ambulatory surgery centers are in the works: an orthopedic, plastic and pain surgery center in Westmoreland and another for pain management in either Utica or Kirkland.”

“The facilities are just the latest step in a decades-old march of services moving away from hospitals into community settings, whether that be an X-ray machine in an orthopedic surgeon’s office, chemotherapy in a doctor’s office or stitches in an urgent care center.”

The availability of so many services in the community raises the question: Do we still need hospitals?” Maybe not, pundits predict more than half of hospitals may close in the next decade.

But of course, we need hospitals – for major procedures, for serious diseases and complications, for trauma, for treatment of burns, for emergency care, for pediatric care, for all sorts of psychiatric treatments.

“The major difference between a medical office and a hospital is access,” said Dennis Whalen, president of the Hospital Association of New York State. “The hospital is open 24/7, 365 days a year. Anybody who walks into a hospital is required under the law to be treated, regardless of their ability to pay.”

These trends will continue. And a new phenomenon, independent free-standing emergency rooms, is cropping up.

Health-care reform is reshaping the mission of hospitals. Gone are the days when hospitals’ major profits were in surgical procedures.
Now hospitals must find ways to replace lost surgical revenues – with joint ventures with specialists, with ownership of outpatient surgery centers, with hiring of specialists, or be declaring themselves as center to prevent disease and restore health to their communities, while making these ventures profitable, or in some cases, closing their inpatient doors.

Sunday, June 29, 2014

In scanning today’s news I came across 3 stories that showed the power of instant information, social media, and #hashtags to transform commerce and world events.

One was the collapse of shopping malls confronted with online shopping.

Two was the rise of ISIS (Islamic State of Iraq and Syria) triggered by use of #hashtags to mobilize Islamic militants.

Three was the use of the Internet by a large health care organization in Pittsburgh to define its customer base and to keep its hospitals profitable.

These stories got me to thinking how hashtags are changing the world.

According to Wikipedia,

“A hashtag is a word or an unspaced phrase prefixed with the number sign ("#"). It is a form of metadata tag. Words in messages on microblogging and social networking services such as Twitter, Facebook, Google+ or Instagram may be tagged by putting "#" before them, either as they appear in a sentence, (e.g., "New artists announced for #SXSW2014MusicFestival")or appended to it.”

“Hashtags make it possible to group such messages, since one can search for the hashtag and get the set of messages that contain it. A hashtag is only connected to a specific medium and can therefore not be linked and connected to pictures or messages from different platforms.”

“Because of its widespread use, the word was added to the Oxford English Dictionary in June 2014,[defined as: hashtag n. (on social media web sites and applications) a word or phrase preceded by a hash and used to identify messages relating to a specific topic; (also) the hash symbol itself, when used in this way.”

This definition got me to thinking how the Internet and the social media, using the power of #hashtags, has transformed health care.
Centralized institutions – government and big health organizations in the medical industrial complex like hospitals – have recognized that the Internet and the social media, using hashtags are a powerful way of adjusting to the waves of centralization and decentralization occurring everywhere in societies and nations across the globe.

With health reform in the U.S. and no doubt elsewhere, it is now recognized that people, i.e., health care customers, prefer to treated in outpatient ambulatory settings away from institutions with inpatient populations, hence the rise of decentralized ambulatory care diagnostic and surgical centers, more home care and outpatient hospices, the movement towards more direct care in physicians offices, the acquisition of decentralized physician practices, and the emergence of free-standing emergency rooms.

The irony of this is that it takes centralized power - organizational and management and marketing skills - to make decentralization work effectively and efficiently. In a sense, many acquired physician practices have become hospital and large organizational franchises.

On the other side of the coin, independent physician practices and organization need centralized guidance and support to remain independent.

I discuss the importance and inevitability of this interdependence of centralized and decentralization in my new E-book , Direct Medical and Surgical Care, which will soon be available on Amazon and Nook, and in 3 books I am now writing which will be called the ObamaCare Triology. This triology will be published after the November midterm elections. These elections will likely determine the shape and fate of ObamaCare.

Friday, June 27, 2014

ObamaCare Premium Hikes Inevitable
There is no good arguing with the inevitable. The only argument available with the east wind is to put on your overcoat.
James Russell Lowell (1891-1891), American poet, critic, author, and diplomat, Democracy

With health exchanges plans and with health plans in general, premium hikes are inevitable.

Sick people require higher rates, and health insurers with investors have to stay in business.

More sick people are going to sign up for federal subsidies than well people.

That is precisely what is happening with the health exchanges. That is why premium rates are going up. And that is why the ObamaCare prognosis is grim.

Obama promised family premiums would go down $2500. Instead a $5000 swing has occurred with rates going up at least $2500.

The inevitable premium increases are one reason why, among other dismal economic factors, such as the 2.9% contraction of the GDP last quarter, why Americans may vote for a Republican Senate in November. This contraction may be due to the Winter of Economic Discontent, but there are other reasons as well.

It was inevitable that more sick people would sign up for the exchanges. They need the care.

It was inevitable that 27% of those signing up would have serious medical conditions like diabetes, cancer, health conditions, and other ailments, more than double the number of those who choose to hang on to their existing plans.

It will be inevitable that insurers will have to raise premiums to catch up with insurers’ expenses of caring for the sick.

It will be inevitable that government will have to “bail out” insurers for their losses through “risk corridors.”

All of this is inevitable when government mandates that private insurers have to cover all those with “pre-existing conditions;“

when insurers cannot ask what those conditions are;

when government itself must relegate coverage to others because it does not have the expertise to manage coverage;

when data is not available or is not yet forthcoming to judge what coverage costs will be;

when one-size-fits-all government policies require that everybody must pay for conditions that may occur with others but not themselves;

and when the entitlement state engulfs us all.

So put on your economic overcoats. It's inevitable it will be cold outside and political condition frigid inside for some time to come.

A: With ObamaCare, costs and premiums continue to rise, promises to keep your doctor and health plan are in shambles, and average of public polls indicate only 38% approve while 51% disapprove.

The State of the Union is equally bad. The economy shrank 2.9% in the last quarter, Obama's job approval as dropped to as low as 40% (CBS/WSJ), 54% disapprove of Obama's handling of the economy, 55% think economy is getting worse, 63% of the people say the country is headed in the wrong direction, effective unemployment is around 13%, only 27% approve of Obama’s handling of foreign affairs, and news of the so-called scandals at the IRS and the VA, defeats in Iraq, and the Benghazi affair dominate the headlines. It will be difficult for the Obama administration to turn all of these negatives into a positive.

Q: Why do think ObamaCare is in such turmoil?

A: Seven reasons, especially when placed in context of the negatives above.

• Its partisan passage without a single GOP vote.

• Its broken promises.

• Its failure to contain premiums.

• Its one-size-fits-all philosophy.

• Its negative effect on the middle class.

• Its negative impact on doctors.

• Its coercive mandates infringing upon American’s freedoms of choice and individual liberties.

Q: Explain.

A: Its partisan passage was arrogant, poisoned the political environment, and rendered compromise nearly impossible.

Its broken promises – you can keep your doctor and health plan are self-evident- are politically toxic because the administration knew about them beforehand.

It has not contained premiums which are rising faster than before ObamaCare, at unpredictable rates, but fastest in the individual and small group markets.

Its one-size-fits-all philosophy, namely that all federally-sanctioned plans must contain 10 essential benefits, whether you need them or not, makes no sense to those who do not need these benefits, and raises premiums for everybody, especially the young who see themselves paying to support others.

Its negative effect on the white middle class who view themselves as financing Obama’s dream of equal outcomes for all based on economic class, rather than equal opportunities for all based on skills, talents, entrepreneurship, and economic growth. ObamaCare has slowed economic growth. The U.S. 43% corporate tax harms economic growth and undermines the idea that a rising tide lifts all boats.

Doctors are disillusioned with ObamaCare. It cuts their reimbursement and burdens them with bureaucratic paperwork. It blames them for rising costs, and in effect, drives them out of private practice into hospital employment or retirement or into direct pay/concierge medicine, all of which aggravates the doctor shortage.

The coercive impact is largely ideological and stems from the individual and employer mandates which say you must knuckle under to the government or pay economic penalties. This impact has created a partisan divide among Democrats and Republicans over ObamaCare. The latest Kaiser tracking poll, dated June 19, indicates the following. Among Democrats, 20% say ObamaCare helped their healthcare, 65% said it had no impact, and a mere 8% said it harmed their care; among Republicans, 5% said it helped, 54% said it had no impact, and a whopping 37% said it harmed their ability to get or to pay for care.

Q: So what do you conclude?

A: I conclude ObamaCare is unworkable or harmful for many, particularly the white middle class who tend to turn out for midtwerm elections. Among the 8 million who signed up on the exchanges, most were in poor health or were uninsured. That is good. Its future is uncertain. I believe its fate hangs in the hands of voters in November. Perhaps, as Mark Twain (1835-1910) said of Richard Wagner's music, " It's not as bad as it sounds."

Tuesday, June 24, 2014

Big Questions on Health Care for Middle Class
Not all big questions are answerable.
Anonymous

For many questions, there are not two sides;there may be a score of valid shades of opinion.

Bergen Evans (1904-1978), lexicographer and educator

Please indicate if you think questions are answerable.

• Are you better off economically than you were 5 years ago?

• Do you think redistribution of health care benefits from the haves to the have-nots is a good idea?

• Are your health care premiums and deductibles more affordable than they were 5 years ago?

• Have you had problems finding a primary care doctor to care for you?

• Do you think it is government’s responsibility to provide affordable health care for all citizens?

• Has your health plan been cancelled recently?

• Is your doctor now in the network of your insurance plan?

• Do you think all health plans ought to cover all essential health benefits or just the ones that apply to you?

• Do you believe in a single payer system such as Medicare for the middle class, Medicaid for the poor, or government subsidies for those making $46,000 or less?

• Do you prefer government-controlled-and-directed care or market-based care based on personal choice?

• Who do you trust most – government or markets?

• Do you think that your personal health care data should be accessible to employers or government or health plans?

• Should doctors, hospitals, or other health care providers be free to charge cash for their services?

• Should government require you to have a health plan or pay a penalty?

• Should all employers be required to offer health plans for workers?

• Should all health expenses for individuals be deductible?

• Should you be able to shop across state lines for health insurance?

• Do you trust doctors to do the right thing for you and your family?

• Do you think health savings accounts, sometimes medical savings account, which require you to pay cash for routine primary care services or routine surgeries, but with a lid for more expensive or catastrophic services, are the righ the thing to do?

• Should first dollar coverage for all health care services be the law of the land?

• Is health care a right or a privilege?

• Do you approve or disapprove of the Accountable Care Act (ObamaCare) law as written?

Monday, June 23, 2014

Obamacare Alphabet Soup- 4 R’s and 2 C’s
Politics is a game of alphabet soup.

Anonymous
Senator Tom Coburn, (R. Oklahoma) , says Republicans ought to change their ObamaCare strategy from the old 2 R’s (Repeal and Replace to the new 2R'sRescue and Recovery).

In Coburn’s words:

“Now that the Affordable Care Act's subsidies have kicked in and millions have supposedly enrolled in exchanges, much is being said about Republicans backing away from repeal and replace. I would propose a more honest and accurate phrase about what comes next: rescue and recovery.”

Here is what Coburn suggests for the “rescue and reform” effort.

“The plan I recently introduced with Sens. Richard Burr, R-N.C., and Orrin Hatch, R-Utah, called the Patient CARE Act, will do everything ObamaCare promised to do with less cost and better outcomes. A few key provisions:

“• Individual Americans have the freedom to shop for their own health care through a means-tested tax credit that helps lower-income people the most.”

“• The plan adopts policies that will make the market more transparent, competitive and responsive to consumer demands. Our society trusts the market in every area except health care and education. That needs to change.”

“• Health savings accounts will be expanded, allowing consumers to keep more of their dollars for their health care needs.”

“• States have greater responsibility and accountability for designing Medicaid solutions that work for their own state without blowing a hole in the budget.”

“• The plan puts the brakes on the practice of defensive medicine — another driver of health care costs — by suggesting medical liability reforms.”

“• Solve the pre-existing condition problem by creating a new continuous-coverage consumer protection that allows people with coverage to move onto a new plan without being medically underwritten for a new plan.”

And here are Coburn’s thoughts about the 2 C’s:

“Simply put, our Patient CARE Act highlights the real choice: the one between the ACA's government-centered coercion and the individual patient's personal choice and freedom.”

“Markets aren't perfect, but history shows that nothing distributes scarce resources more fairly and efficiently. We've tried the government-centered approach. It isn't working -- just look at the Department of Veterans Affairs. It's long past time to put patients in control and let freedom work.”
Rejoinders

The Democrat rejoinder to Coburn’s remarks would surely be “R” stands for patients’ Rights, as guaranteed by government. To which Republicans would reply, yes, and “R” stands for Rationing too , a characteristic of government-run systems, as exemplified by the Va’s long waiting lists.

Sunday, June 22, 2014

Computer Use to Bring Order Out of Health Care Chaos

The purpose of computers is to bring order out of chaos.

Anonymous

This week I escorted a patient to a surgical ambulatory care center.

Everywhere we stopped or went , there was a computer - at the reception desk, at the vital sign and weigh-in station, at the prep room, at the waiting room for visitors, in the operating room, in the recovery room, at the check-out room, in the parking lot, even after we returned home.

Everything was wired – before, during, after surgery, and even after return home. Everything was anticipated every step of the way. Everything was followed. Everybody seemed comfortable with the computer. I was impressed.

The computer brought order to what could have been chaos. The ambulatory surgical center did 50 procedures that day – everything from parathyroid adenoma removals, to thyroidectomies, to endoscopic cholecystectomies, to exploratory laparotomies, to cystectomies, to ophthmalmogical to urological to orthopedic to cosmetic procedures.

I knew the whole idea behind this widespread computer entry and tracking system was to bring order out of chaos. I knewthe other idea was to broaden the ambulatory care surgical care knowledge base. I knew a third idea was to avoid any mis-identification of patients and to avoid malpractice problems later. I knew you needed a computer to record charges for what was done and by whom.

I knew computers sometimes disrupted work routines, and slowed the pace of work. But I saw none of that. Everybody seemed well trained and at ease with digital technologies.

Computers are here to stay. You can’t live without them. And sometimes, as is the case with healthcare.gov endless glitches and with Lois Lerner’s two years of lost emails, and computer hacking and identify-theft, the world knowing everything about you under the sun, and doctors’ time wasted making endless computer entries, it’s hard to live with them.

But all that aside, computers are great for organizing work flow, for accumulating mountains of data, for advancing and broadening your knowledge base, for having improving care by measuring it and having a base to improve upon, for defining patterns of care and outcomes individual can’t, and lately, for manipulating and storing information “in the cloud” in data storage servers outside your personal computer, laptop, or cell phone, or computers at work, and for selling your services on the Internet.

Computers are a mixed blessing. You need them to measure how well you’re doing and to improve upon your work. You need them to find information quickly. You need them to find if a patient is qualified to pay for your services. You need them to track a patient’s vital signs or changes in laboratory or physiological tests. You need them to look up things about a disease or the efficacy of a procedure.

At the same time, if you’re a doctor, computers can be a curse. The money spent to install them in your office and to train your staff drive up overhead. The time required to make data entries is time spend away from patients. . The effort expended to find just the right code is a nuisance Setting aside time to answer all those emails is a pain. Figuring out how to work your way around or through a program obstacle you don’t understand is annoying. Finding just the right electronic health record to fit your particular needs or specialty or type of practice (direct pay practices that are insurance free require much simple systems) takes more time and expertise you may not have.

Someday some aspiring or savvy writer will write a best seller Of Time and the Computer. It won’t be me. I don’t have the time. Still, thank goodness, there will be computer that tracks your royalties.

His nature is too noble for the world…His heart’s his mouth; What is breast forges, that his tongue must vent.

Shakespeare (1564-1616), Coriolanus

In its obituary today, the New York Times characterized Dr. Arnold as “outspoken.”

Outspoken he was. When I interviewed him 26 years ago, he struck me as an academic medicine professor turned preacher and evangelist for progressive causes. The interview appeared in a 1988 issue of Minnesota Medicine and was entitled “Arnold Relman’s Thoughts on The Journal and Medicine’s Future.” The Journal, of course, was The New England Journal of Medicine, of which he was editor from 1977 to 2000.

His driving cause was eliminating for-profit medicine:

Single-payer medicine. In the words of The Times, “His prescription was a single taxpayer-supported insurance system, like Medicare, to replace hundreds of private, high-overhead insurance companies, which he called ‘parasites’ .To control costs, he advocated that doctors be paid a salary rather than a fee for each service performed.”

His targets of contempt were:

Profit-driven insurance companies, pharmaceutical companies, device manufacturers, hospitals and nursing homes, diagnostic laboratories, home-care services, kidney dialysis centers, and any health care business that made a profit out of healthcare.

One should simply not make money of medicine. It was too noble a profession and too altruistic an undertaking to pursue for the almighty dollar. Profiteering in any form was a no-no. The “medical industrial complex,” as he called it in a 1981 New England Journal of Medicine, was rotten at its core.

As he put it, “The private health care industry is primarily interested in selling services that are profitable, but patients are interested in services that they need.”

Distracters once called he and his wife, Dr. Marcia Angell, a pathologist and later an editor for the New England Journal of Medicine, , “Medical Don Quixotes, completely deluded figures of the landscape,” but admirers looked upon them as “first responders in the battle for the soul of American medicine.”

The couple shared a George Polk Award for 2002 New Republic article documenting how pharmaceutical companies spent more money on advertising and lobbying than research.

In my interview with him, Relman concluded:

“Free market principles simply do not apply to medical care. The practice of medicine is based on the Samaritan tradition. My concern is that when you try to make what is basically a social service and a professional relationship between a doctor and a patient into a business, you have a clash of two incompatible sets of values. In my opinion, that is one of the main problems the American healthcare system is facing today. We can’t decide. We don’t have a clear vision of what we want our health care system to be. Do we want it to be a business, or do we want it be a social service.”

Relman thought any attempt to covert medicine into a market economy was a “complete failure.” In 2012, he said he regarded ObamaCare as partial reform at best, and he said medical profiteering was worse than he originally imagined. A more aggressive solution was needed, and that was single-payer, a common view when seen through the Boston academic-prism.

Relman was a man of strong opinions. He knew where he stood, and where he stood depended on where he sat, at the helm of America’s and perhaps the world’s most prestigious academic medical journal

Friday, June 20, 2014

In 1984, Ben Wattenberg (born 1933) , an author, columnist, and speechwriter and consultant to Lyndon Johnson and Hubert Humphrey, wrote The
Good News is the Bad News is Wrong(Simon and Shuster).

In
his book, Wattenberg insisted things were not really as bad as they seemed
despite the doomsday rhetoric of the day.

Sound familiar?In
the case of ObamaCare critics, the title might be changed to read The
Bad News Is The Good News Is Wrong.

The good news, says the Obama administration and its
supporters, is that things are going swimmingly for the ObamaCare health exchanges. (See
MSNBC,“Everything Is Coming Up Aces for
the ACA,” and New York Times, “Good
Progress for Affordable Health Care.”

The good news story goes:

Eighty seven percent of people signing up for the exchanges
are actually paying their premiums;85%
are receiving government subsidies; more insurance companies are joining the
exchanges’ consumers are having more choices than originally planned; large government
subsidies are helping low-income Americans get coverage;the exchanges encouraged millions of more Americans to join the Medicaid rolls;and a benevolent government is paying for 76% of
it all, especially for the poor and uninsured.

But alas, not so fast.Insurance analyst Bob Laswewki notes,” It would appear the lowest income
people are the most often signing up for coverage.That explains the average consumer is to high
an average net cost is so low.”

The good news is that 8 million signed up for the exchanges
and 3 million joined Medicaid.

The bad news?What about
the 310 million who did not sign up and the 60% to 70% of Americans who will
not qualify for subsidies because their incomes exceed $46,000 ?

And what about those Americans are priced out
of the market because of an average of 30%higher premiums and $6000 deductibles? \Says
Laswewski, “ObamaCare looks to be on its way to crating a chronically uninsured class.”

ObamaCarehas
effectively made health care coverage more and more expensive for more of the
Middle Class,whose average income has
dropped from $55,000 to $51,000during
his administration and who now must pay higherpremium and meet$6000
deductibles .

As one such Middle Class person, commented,” It’s like
having no insurance at all.”

What if the
Middle Class,or even if the
insured,are unable to pay the premiums
or to find a doctor who will accept those in ObamaCare plans to pay for care up
to the deductible when they need the care?

Some will go on Medicaid,some
will try to qualify for subsidies, some will go to direct pay physicians whooffer affordable retainers,some will ask for cash discounts.

And in many cases,hospitals and doctors will take a financial hit
because they are legally or morally obligated to provide care for those who
need it.

Not to worry, says the New York Times,“Americans are finding very affordable care
and a wide choice on the plans operated by the federal government.”

But what about those with no plans or those not operated by
the federal government?

And what about those false promises that under
ObamaCare health care would “be better for everyone,” would cut the average family
premium by $2500 when the reverse is true, and what about the promise that ObamaCare
would “bend the cost curve” for the “average person”?

The answers will depend on voter opinions, as expressed in
the polls in November 2014 and November 2016, and on what “average person”
means and upon what those persons think who are not content to be “average.”

The Health Reform Maze

Buy the Book

Book Description: In this first book in a series of four, Richard L. Reece, MD. provides a unique view of the roll out, and run up, of the Affordable Care Act. Reece shows in this book the progress and facets of ObamaCare's marketers and messengers, as the day approached for the launch of health insurance exchanges - the single most public and problematic portion of the new law. This is a must read for anyone who wants to chronicle this attempt to organize more than one-sixth of the U.S. economy by adding layers of federal government control and regulations.

Reece has been writing about U.S. health care for more than 45 years. His knowledge and experience, added to his keen intellect and gift of subtle humor, make this book a valuable part of anyone's collection.